Role Of Pharmacy In Health Promotion Health Essay

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The term Health Promotion has become widely used in the discussion of Public Health, but often with no clarity as to what it is and what the role of a health promoter is, due to the field of health promotion seeing considerable change throughout history.(1) The 19th century displayed an emphasis on disease prevention due to epidemic disease arising in overcrowded industrial towns leading to the prominence of sanitary reform. However, morbidity and mortality patterns in the later 20th century saw a shift in approach to health promotion, turning away from disease and focusing on altering personal habits and behavior using an educational approach.(2)

According to the World Health Organisation, Health Promotion is defined as 'the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.' (3) This interpretation seems to be one of providing the information and advice, in order to give the individual the best possible opportunity to make an informed decision.

1.3 Role of Pharmacy in Health Promotion

Pharmacy, in all sectors, is becoming increasingly recognized for its contribution to the field of public health, working to provide self-help and health information and advice to the public, with the aim of improving health and social care quality. (4) As part of the NHS Community Pharmacy Contractual Framework, pharmacies offer specialist services such as smoking cessation, sexual health screening, diabetes and blood pressure screening services and many more. In addition, they also provide signposting to other organisations, developing professional relationships with local authorities and other healthcare professionals. (5)

According to the Pharmaceutical Services Negotiating Committee (PSNC), pharmacies are obligated to host six public health campaigns per year as a requirement of the NHS contract for Pharmacy, involving a display in co-ordination with the local Primary Care Trust (PCT). (5) The proposed events for this project mimic the process of setting up a health promotion campaign that each PCT requests of pharmacies.

Pharmacy plays a key role in reducing harm associated with substance use, justifying the purpose of this project. One approach is free needle and syringe exchange schemes for injecting drug users (IDUs), in order to reduce harm from using unsterile needles for illicit drugs. The pharmacist is also involved in supervised methadone administration, as an oral substitute drug for those patients being treated for opiate addiction. (5) Both of these health promotion approaches are key in reducing spread of HIV infection and improving management of substance abuse in local areas. (4)

The NHS Improvement Plan has set out Public Service Agreement (PSA) targets as key deliverables for the NHS. One of the deliverables on which they have focused, is the provision of services for substance misusers by the pharmacy. The Department of Health appraised pharmacy input to this target by looking at the importance of the identified health problem and also by looking at the strength of existing evidence for the intervention. It was concluded that it had "considerable impact" on the health of the population who misuse substances in the UK. (4)

The NHS, however is looking to further promote the wide range of accessible services which pharmacies provide, extending their influence in improving health and reducing health inequalities.(4) According to the Government's White Paper, Choosing Health: Making healthy choices easier', pharmacies will play a key role in the 'health-promoting NHS' particularly community pharmacies as their accessible location, convenience and quite often extensive opening hours, are providing opportunities for advancing community involvement. (6) Pharmacists will acquire an aptitude for identifying risk factors and working in co-ordination with local authorities and other health organisations to develop a strong local network of improvement services. They will also be involved in health promotion in local schools and workplaces, fostering a strong relationship with the wider community. (4) Another area for development that has been acknowledged is establishing public health as a key principle in the undergraduate pharmacy curriculum. (4)

In June 2004, Health Minister Rosie Winterton MP stated, "To date pharmacists have been a major untapped resource for health improvement. The track record of community pharmacists in areas such as stopping smoking, sexual health advice and substance misuse is evidence of how integral they are to tackling public health issues. But we would like pharmacists to do even more."(4)

As health issues continue to rise and the need for enhanced public health promotion is emphasized, the public will become more dependent on the pharmacy as their primary source of personal support. Pharmacists are recognized for their non-judgmental attitude in offering advice on sensitive issues such as needle and syringe exchange, and perhaps for this reason, the public has placed their trust in them as their allied healthcare professional. (4)

2. Background of Substance Misuse

2.1 What is Substance Misuse

Substance Misuse can be defined as the consistent excessive consumption of a psychoactive substance, used in a way that is not intended, without medical approval, causing harm to the individual. (7) The Royal College of Psychiatric Surgeons defined it as "any taking of a drug which harms or threatens to harm the physical or mental health or social well-being of an individual, or other individuals, or a society at large, or which is legal." (8) This definition suggests this problem to be a severe health risk and provides strong reasoning as to why health promotion in this area is critical.

2.2 Substances Commonly Misused

2.2.1 Illegal Drugs

The most common illegal drug used to date in the UK is cannabis, also known as "marijuana" or "weed" (9) and is a Class B drug It is derived from the plant cannabis sativa and the active component of the plant, which gives the high, is delta-9-tetrahydrocannabinol. Users experience hallucinogenic effects such as mild euphoria and relaxation. Harmful effects experienced during the 'high' may include drowsiness, loss of well-being, and loss of co-ordination, anxiety and paranoia. (10) Inadequate research has been carried out regarding long-term effects of cannabis misuse, however evidence suggests there are possible risks of testicular cancer (11) and lung cancer (12), links to respiratory complications and disease (13), deterioration of memory and cognitive ability over time (14) and associated mental health problems (15).

Ecstasy, also known as 'E pills' or by its chemical name MDMA, is a Class A drug associated with the rave culture of the clubbing scene due to its associated effect of keeping users awake and therefore providing the ability to stay awake all night.

(16) It chemically acts as a stimulant producing distortions in time and perceptions (17, 18) by altering the activity of chemical neurotransmitters that enable nerve cells in the brain to communicate with each other. Research has shown that ecstasy can have toxic long-term damage on nerve cells that contain serotonin, (17, 19) has been known to cause convulsions and hallucinations, (20) and can cause the body to overheat uncontrollably until the user becomes unconscious. (21)

Cocaine or 'coke' is an addictive Class A stimulant that acts on the brain by blocking the removal of dopamine from the synapse, causing a build-up of dopamine. This produces euphoria and mental alertness, particularly in response to light, sound and touch. (22) Research has revealed severe medical complications associated, particularly cardiovascular effects. In the first hour of cocaine use, the user's risk of heart attack is almost 24 times greater. (23)

Heroin is a Class A drug made from morphine, an opioid analgesic. It is used as a recreational drug for the intense rush and a surge of euphoria it produces. However, tolerance and physical dependence rapidly develop requiring the user to take larger doses to attain the desired effects, quickly leading to addiction. (24) Heroin also suppresses the respiratory system, which can be fatal. The most prominent issue however, is the intravenous route of administration with unsterile needles and syringes, particularly when shared among users, leading to an increased risk of HIV infection or hepatitis. (24)

Ketamine is a dissociative anaesthetic, and serves as a Class C drug for clinical use in human and veterinary surgical procedures. It causes users to feel detached from the immediate environment and self. (25) This is a result of the action on the central nervous system, namely blocking the N-methyl-D-aspartate (NMDA) receptors. (25) There is limited evidence available on long-term effects of repeated abuse, however, impairments in thinking ability and psychological well-being have been reported in frequent users. (26)

Mephedrone was a legal high but has now been controlled under the Misuse of Drugs Act making it a Class B illegal drug as of April 2010, due to the growth in prevalence of its' misuse and the potential harm associated. (27)Mephedrone is a hallucinogenic stimulant on the central nervous system, and is similar in effect to cocaine, amphetamine and MDMA. (28) Self reported subjective effects include stimulation and euphoria. (27) Due to the novelty of mephedrone, most reports of harm are self-reported. Of the few clinical data present from toxicology departments in hospitals, toxic effects take the form of uncomfortable changes in body temperature, vomiting palpitations and seizures. (27)

2.2.2 Legal Highs

Novel psychoactive substances, also known as research chemicals, or 'legal highs' are a relatively recent phenomenon and according to the Advisory Council on the Misuse of Drugs, they can be defined as "named and specific substances which are designed to be similar chemically and/or pharmacologically, to known specific controlled drugs." (29)They hold the legal status because as of yet, they have not been controlled under the Misuse of Drugs Act. This is, in part, due to the fact that experimentation with different analogues of drugs causes the market of legal highs to be constantly changing. Little research has been carried out to investigate their composition or the potential harm they can cause, to which lies the potential harm in the human use of such untested substances. (29)

Barbara O'Brien, manager of MOSAIC, a school-based drug service in Stockport, Manchester, provided us with a briefing from KFx, a drug consultancy initiative which provides information on the most recent drugs entering the market. (30) This informed us of the most predominant research chemicals currently in Manchester, in order to focus our research and consequently present the proposed drug education in schools on these prevalent chemicals.

Benzofury contains the chemical 6-APB, which is a stimulant, chemically very similar to ecstasy and can act like an amphetamine.(30) However, it may also contain other substances such as 5-(2-aminopropyk) benzofuran and the now illegal Class B drug, D2PM. (31) The drug is legal to possess therefore misrepresenting itself as being safe to use. Whilst the pleasant effects may include increased love and affection for others, users experience paranoia, anxiety and panic attack. Risks of overdose and over-heating are high. (31)

Annihilation is a synthetic cannabinoid, containing the chemical MAM2201, (32) another popular substance on the current market. It is known to mimic the effect of THC at cannabinoid receptors, but has the potential for being more potent, and therefore more dangerous. It displays effects equivalent to that of strong cannabis, such as exhilaration, confusion and the sensation of feeling stoned, and is associated with many harmful effects according to research carried out by KFx. These include numbness of limbs, loss of consciousness, respiratory distress and acute mental illness. (30)

Alphamethyltryptamine, more commonly known as AMT, is a long-acting hallucinogenic, aimed to mimic illicit hallucinogenic drugs such as LSD. (30) The risks of AMT lie in the lack of control and unpredictability of a "trip," and flashbacks can occur any length of time after the original experience triggering anxiety and panic. (30)

2.3 Factors associated with Drug Use

There are a number of proposed reasons for the misuse of substances, and various patterns tend to emerge. Researchers have found that, particularly in the preliminary stages of misusing drugs, it often takes place in a group or party situation "where the drugs serve as the centre of social interaction and may provide individuals with a sense of group identity." (33) As adolescents become more dependant on peers, there tends to be a consequential increase in conformity pressure, (34) and in the case of peers misusing substances this proves to be a predominant issue.

Through the adolescent years, many developmental factors influence the experimentation of drugs. As young people try to grow independent of their parents, they will attempt new behaviours to acquire a personal identity and a sense of autonomy. A recurring mannerism is an ignorance of harm and long-term destruction that drugs can cause. Young people demonstrate an intentional lack of concern particularly in the preliminary phase of experimenting with substances. (35)

Research has shown that individuals, who have little knowledge of the adverse effects of drugs, are at increased risk of becoming substance misusers than those who have a better comprehension of their consequential harm, and carry a negative attitude to their use. Likewise, those who view substance use to be prevalent and commonly practiced are more liable to participate. (35)

What appears to be a leading factor, however, in the prevalence of substance misuse is the behaviour and mentality of the parents and family. Children and young people who have family members or role models in their life, who misuse drugs, are at considerable risk of developing substance misuse problems themselves. (35)

The Smoking, Drinking and Drug Use among young people in England in 2011 report used the Logistic Regression Model to display factors associated with substance misuse in the last year. The model enables us to control other factors in order to study one specific factor, and allows assessment of the strength of the relationship between these considered factors and prevalence of drug misuse. (36) It was found that boys were more likely to have taken drugs in the last year; pupils of Asian ethnicity were more likely to have taken drugs in the last year; and pupils who already smoked were more likely to have taken drugs in the last year than those who did not smoke. (36)

It is apparent from the literature that there is no single cause of substance misuse, but in fact there are many factors responsible. This mystery of the underlying cause makes it much more difficult to intervene and prevent it from happening, however, the associated factors that have been mentioned are of great importance when considering the effectiveness of prevention methods. For this principle motives mentioned, such as lack of knowledge of harm and misconceptions of extent of drug use by peers, it has been decided to investigate young peoples' awareness and perceptions of frequently misused drugs and their harmful use.

2.4 Outcomes of Drug Use

2.3.1 Hospital Admissions

From 2001 to 2009, according to Hospital Episode Statistics (HES), England saw a positive substantial decline in hospital admissions regarding primary diagnosis of a drug-related mental health and behavioural disorder, from 8,027 to 5,668. (37) However, since 2009, admissions have rose again to 6,640 in 2011. Evaluation has shown these statistics to include 'other stimulants' category, and 'multiple drug/psychoactive substance use.' (38)

HES reported hospital admissions for drug poisoning to be at an even higher rate, with 12,568 individuals admitted to hospital for poisoning by drugs. This figure has gradually increased since 2001, by 61% in a ten-year period. (37) It emerged that the age group displaying the highest rate of admission was young people aged 16-24, with 3,202 admitted in 2010/11 for primary diagnosis of poisoning by drugs. (37) This could potentially suggest a lack of awareness of the degree of harm these drugs cause, as well as increased naivety in this age group.

These statistics reveal the severity of this issue, particularly with regard to an acute effect on young people. The prolonged effect it is having on the NHS is also a requisite for action.

2.3.2 Drug-Related Death

The Office for National Statistics (ONS) published an account of the Deaths Related to Drug Poisoning in England and Wales 2011. (39) In 2010, 2,747 people were reported dead due to drug poisoning. The highest rate of deaths due to substance misuse occurred in the 20 to 38 age group for men, and 40-49 age group for women. In 2010, nearly one in seven deaths of young people in their twenties, was accounted for by drug poisoning incidents. (39) Similarly in regard to hospital admission statistics, these figures suggest a potential lack of awareness of drug-related harm, and evidently a lack in safe usage.

It is difficult to associate specific drugs to individual deaths, as 12% of death certificates concerning drug-related incidents only provide a general description such as "drug overdose" and a further 30% of cases may mention numerous substances used but unknown cause of death. (39) However, in 2011 it was found that 112 death certificates reported cocaine to be the cause; there were 56 reports of amphetamine deaths; and 8 of these due to ecstasy; 11 deaths were due to cannabis and 6 due to Mephedrone. (39)

There are a variety of contexts under which drug-related deaths can occur, including accidents, suicides, problems of drug abuse, and drug dependency. The leading cause of death was found to be accidental death by drug poisoning, particularly in males, where 48% of drug-related deaths were accidental. (39)

3. Prevalence of Recreational use

3.1 Substance Misuse among Young Adults

The 2011/12 Crime Survey for England and Wales (CSEW) is the most recent survey of illicit substance misuse in the UK. This research conducted by the Home office has displayed a substantial increase in drug misuse among the 16-24 age group, in comparison to the adult population as a whole. (40)

The CSEW studied the levels of frequent drug use, that is 'having taken any illicit drug more than once a month on average in the last year.' The 2011/12 survey estimated that 7.0% of young people aged 16 to 24 frequently used drugs. This figure was twice as high as the 3.3% of the 25-54 age group frequently using drugs. Among young people who stated they took drugs in the last year, two in every five (41%) were frequent drug users. (40) From the evidence provided, a heightened prevalence of frequent drug use is apparent in young people, suggesting that this is the target group for which concern must be raised.

However, data has clearly shown a gradual decline in substance use among young people since investigations by the Home Office began in 1996, with a drop from 29.7% to 19. 3% of 16 to 24 year olds using illicit drugs in 2011/12. The Use of Class A drugs among 16 to 24 year olds in the last year had also fallen to 6.3% in 2011/12 from 9.2 per cent in 1996. (40) Table 3.1 displays this steady decline, in prevalence of drug use, particularly from 1998 onwards.

Table 3.1 The trends in last year illicit drug use among young people aged 16 to 24, from the 1996 to 2011/12 Crime Survey for England and Wales (CSEW). (40)

3.1.1 Extent and Trends of Individual Drug Use

In correspondence with the decline of overall illicit drug use, CSEW has seen a notable drop in the use of Class A drugs in the last year by 16 to 24 year olds from 9.2% in 1996 to 6.3% in 2011/12. This gradual decline has partially been due to a fall in the use of ecstasy in the last year (6.6% to 3.3%) and hallucinogens (from 5.3% to 1.4%). However this has been counterbalanced by a slight increase in powder cocaine use (from 1.3% to 4.2%). (40)

Cannabis consistently appears to be the most commonly used illicit drug, as displayed in Table 3.2, with 15.7% of young people misusing it in 2011/12. Cannabis use has fallen from 28.2% in 1998, however the decline in percentage use came to a halt in 2009 and has remained stable for the last 3 years. (40)

Table 3.2 The extent of last year's illicit drug use for most prevalent drugs among young people aged 16 to 24, from the 2011/12 Crime Survey for England and Wales. (40)

Cannabis has been known to be a 'gateway drug' suggesting that young people are more likely to try other drugs if they have tried cannabis. (41) Prevalence of powder cocaine and ecstasy closely follow, with approximately 0.5 million young people misusing these two drugs in the last year, This highlights the importance of targeting these three illicit drugs with effective methods of intervention.

When comparing the figures for Ketamine use in 2011/12 to previous years, levels of ketamine had an initial increase in 2006/7 when it became popular, but levels have been stable for the last 4 years with 1.8% using ketamine in the last year in 2011/12. A fall has also been notified in amphetamine use since 1996, from 11.6% to 2.0% in 2011/12. (40)

CSEW have measured Mephedrone to be the third most prevalent illicit drug now used by young people in England and Wales, with 3.3% of 16 to 24 year olds misusing it, which is the same level of ecstasy used. (40) Adult rates of mephedrone use stand at a significantly lower level of 0.5% in comparison to younger people (40), suggesting that this is notably a popular drug for those aged 16 to 24 years old.

Thus far, the statistics regarding prevalence of substance misuse have been primarily concentrated on controlled drugs. Drug Misuse Declared solely studies controlled drugs and until a drug is declared controlled, CSEW does not investigate its usage. (30)Reliable data on the prevalence of use of research chemicals is heard to obtain due to the rapid alteration of manipulated drugs on the market, making research in this area challenging. It is thus difficult to grasp an accurate representation of how prevalent use of legal highs is. (30) However, the Advisory Council on the Misuse of Drugs has shown that surveys suggest 20 to 40% of young people have tried legal highs, however it was noted that these may be "heavily biased samples." (29)

3.1.2 Prevalence with associated lifestyle factors.

The Home office also presented illicit drug use levels in 2011/12 by paralleling with personal and lifestyle factors. Research found that ecstasy use was around 14 times greater in those individuals who attended a nightclub regularly in the last month, to those who had not visited a nightclub. Use of powder cocaine was 13 times greater in those who attended pubs in the last month, to those who did not attend pubs. (40)

Mephedrone use in the last year was found to be highest in young adults who regularly visited a nightclub (9.7%) in contrast to those who visited a nightclub less frequently (2.6%) and to those who didn't visit nightclubs at all (0.5%). (40) Table 3.3 displays this concurring trend of nightclub visits affecting drug use.

Table 3.3 Proportion of 16-59 year olds reporting use of individual drugs in the last year by frequency of nightclub visits in the last month, 2011/12 Crime Survey for England and Wales. (40)

3.2 Substance Misuse among Children

The most recent survey regarding drug use in children is one by the NHS, Smoking Drinking and Drug Use Among Young People in England in 2011 (SDD11) targeting school children of age 11-15 years old.

The SDD11 reported that 12% of pupils took illicit drugs in the last year, which appeared to be a continuing downward trend from 20% in 2001. (36) 7.6% of pupils reported taking cannabis in the last year, a considerable extent more than any other drug, and boys (8.9%) were more likely to take cannabis than girls (6.3%).

Drug use in the last year appeared to increase with age, with 5% of 11 year olds taking drugs, in comparison to 25% of 15 year olds. (36) When asked what the reason was for first experimentation of drugs at a young age, 54% reported it was "to see what it was like."

3.3 Prevalence in North West

The Smoking, Drinking and Drug Use Among Young People in England - Findings by Region 2006-8, provides key findings by Government Office Region for drug use in 11-15 year olds. The North West of England showed the highest level of drug use with 20% of 11-15 year olds in the North West taking drugs in the last year. (42) Simultaneously, the survey showed highest prevalence of cannabis use in the 11 - 15 age group in the North West, with 12% young people taking cannabis in the last year. (42)

With regard to hospital admissions, North West SHA (Strategic Health Authority) had the highest rate of admissions with 19 people per 10,000 of the population being admitted with a primary diagnosis of drug-related mental health and behavioural disorders. (38)

4. Methods of Intervention

4.1 Intervention in Schools and Colleges

Most drug education programmes targeted at children aged 11 - 18 are school based. This is founded on three principal reasons according to Faggiano et al. who carried out a systematic review on the most effective school-based prevention methods for illicit drug use. Firstly, substance misuse prevention programmes must be adopted in the early development stages before young people ascertain beliefs and outlooks on substance misuse,(43) due to research showing a greater chance of addiction associated with earlier use. (44) Secondly school-based intervention is the most methodical way and provides the best opportunities to reach a wide scale of pupils from across the country. Thirdly, schools can implement and enforce educational policies (43) that will coincide with the school curriculum on personal social health and economic education (PSHE).

Recent reviews of the school-based approach, have suggested that the most successful method is to improve social and psychological skills. (43, 45) A recent review from the World Health Organisation ascertained the effectiveness of promoting a young person's mental well being, (46) as well as noted favorable results when the intervention focused on the school environment and community. This method of prevention was known as the Healthy Schools Approach. (46)

One particular review evaluated school-based prevention for illicit drug use, by assessing the quality of certain randomised controlled trials and case controlled trials carried out. (43) It was revealed that 'skill interventions' appear to be most successful in targeting early stages of substance misuse, as it appears to develop a pupil's decision-making ability. (47) However, Botvin found 'knowledge-based interventions' to have a significant effect on the reduction of cannabis use, after reviewing a follow up two years later. This was due to the heightened awareness of harmful biological and psychological effects forming negative attitudes towards the drugs.(48)

An example of these methods being put into effect is by Drugscope and Alcohol Concern who established guidance for the provision of appropriate drug education in colleges in the UK. (49) It uses various methods such as tutorials and peer education to challenge pupils' perceptions and attitudes regarding drugs. However, the efficacy of this intervention in schools is yet to be assessed.

4.2 Intervention in Universities

Educational establishments such as universities are opportunistic settings for raising awareness of substance misuse and preventing drug-related harm, (50) and according to Drugscope, it has been reported that students consider health promotion regarding drugs and alcohol to be important, and would like more effective interventions put in place according to a survey by Drugscope & Alcohol Concern in joint partnership. (51)

It appears that the US have taken heightened measures to research the effectiveness of methods of preventing substance misuse and associated harm, in colleges and universities. Little evidence, however, is present to suggest UK universities carry out such research into health promotion strategies that are in place, and the health status of their students. (52) This is imperative as results produced could potentially inform schools and colleges on the direction to take with drugs education, resulting in a positive influence on the health and development of students entering university. (50)

Few drug education programmes have been carried out in UK universities, and have been delivered in an understated way. (53) Drug awareness campaigns are often organised in a 'wide health promotion framework' and in conjunction with student unions. (50) However, little is known about their effectiveness. One successful and well-known campaign was 'Study Safely' a non-judgmental, harm-minimisation strategy aimed at university students, cooperatively run by London Drug Action Teams (DATs). An assessment of the campaign's effectiveness showed increased awareness of harmful drugs and their effects among the students who had interacted with the campaign. (54)

A US intervention that is becoming increasingly more common and being initiated in the UK is 'Social Norms Intervention.' It aims at reducing students' misconstrued perceptions of peer drug consumption. (55) Evidence has shown that this may be an effective strategy in preventing cannabis use, (56) however, despite changing students' perceptions on social norms for drug use, more research needs to be carried out to assess effect on behaviour change (57) and the appropriateness of these interventions in the UK.

5. Conclusion

Pharmacy is becoming increasingly recognized for the key role it plays in reducing harm associated with substance misuse. (4) By hosting an event to raise awareness of substance misuse, we hope to make a positive impact in society but also in healthcare by minimizing the financial and time pressure on the NHS and indeed pharmacy, in regard to needle and syringe exchange schemes and supervised methadone administration.

Despite a gradual decline in overall drug use in the UK, statistics portray an alarming issue with what is still seen to be a high prevalence of frequent drug use in the 16 to 24 year age group. (40) Evidence clearly demonstrates that the earlier children and young people initiate drug use, the more likely they are to develop dependence and cause increased harm in later life, (44) so it is imperative to enforce preventative measures at an early age in childhood development, hence why a drug awareness event off-campus is to be directed at secondary school pupils in a local school. Findings suggest a correlation between increased drug use and nightclub visits, as well as increased alcohol consumption. (40) Due to these lifestyle factors having an increased prevalence in the university setting and a high prevalence of frequent drug use seen in the 16-24age group, an event on campus aimed at university students is appropriate and targets these risk factors.

The most recent statistics have shown cannabis, cocaine, ecstasy and mephedrone to be the most prevalent illicit drugs misused in 2011/12 (40)advocating the necessity of raising awareness of these specific drugs. The recent development and the attached enigma surrounding legal highs, as well as the apprehension of their unknown content (29) highlights the need to raise awareness on the harm and lack of safety associated, at the school event and also the university event, in the hope students will be given the knowledge to make an informed decision.

Concerning methods of intervention, the evidence for the effectiveness of knowledge-based interventions in schools advocates taking this approach for the school event. (48) This would involve educating the pupils on the pharmacological and biological effects drugs can cause on the body, due to our pharmacy background.

For the proposed event in the Student's Union at the University, the limited evidence available would suggest that the most appropriate method to approach raising drug awareness would be to host a campaign, empowering students with the knowledge to make informed health choices about their social life associated with drugs, through drug education. A campaign is an effective way of promoting substance awareness to a large sector of the student population. (50)

With regards to the study that will be undertaken, limited research has been carried out to investigate students' perceptions of the harm of drugs and the knowledge of drug harm. The literature suggests these factors possibly affect a young person's inclination to misuse substances, (35) therefore, this study has potential to add to the limited existing research already present on this theory.

6. Aims and Objectives

To raise awareness of the issue of substance misuse in children and young people by hosting two health promotion events, as well as enhancing our understanding of the issue by investigating university students' perceptions and knowledge of the harm substance misuse causes.

The objectives are as follows:

1. To conduct a literature review to further our understanding of substance misuse among young people in the UK and the related harm caused.

2. To host an event in University of Manchester Student's Union, informing students of the risks and dangers of substance misuse, and evaluating students' perception and knowledge of harm by data collection methods.

3. To conduct a presentation to raise pupils' awareness of Legal Highs and their associated harm to a group of secondary school pupils in Hazel Grove High School.

4. To signpost young people to relevant authorities for further advice and support.